What is the aim of the pilot?
The model of remote supervision that QRME are proposing is based upon the GP Registrar consulting patients in remote and rural clinics and/or Aboriginal Medical Services (AMS) clinics with the support from a remote GP supervisor(s), experienced clinical teams and established emergency support pathways.
The remote supervision model allows for supervision to be delivered face to face, via telephone and through the use of skype, web/videoconference. As a number of these potential training sites deliver health care to indigenous communities of higher indigenous patient populations, this model also creates increased involvement opportunities for GP registrars to practice indigenous medicine in rural and remote Queensland.
What need does it address?
Based on existing models adopted by other RTPs, the strongest recommendations on how to set up postgraduate training via remote supervision, was that remote supervisor should have time quarantined for this activity and should have an established mentor type relationship with the GP Registrar they are supervising remotely.
The pilot aims to place registrars in some of the remote community health facilities and AMS where there are high clinical demands on the remote area nurses; currently a shortage of GPs; a very temporary GP workforce (short term placements or drive/fly-in/fly-out); or insufficient patient numbers to support two GPs (supervisor and GP registrars).
The QRME site identified for the pilot meet the Vocational Training Standards except for the supervision requirements. The objective of this pilot is to address this by an alternative model of supervision. Individual practices will be encouraged to work with QRME to implement a remote supervision model inclusive of a support team structure.
QRME will undertake rigorous measures, including the following measures in accrediting a remote supervision model in addition to the normal process of training post accreditation:
- site visit ensuring that clinical infrastructure, resources including video and teleconferencing equipment is adequate
- establish role and dynamics of the team as well as their understanding of GP training
- orientation to the practice and rostering of the Registrar within the clinic setting
- what role a Registrar would take in the team
- development of team supervision role plan and team supervision communication plan with signoff by all involved
- design of a team supervision map including sign-off by all involved in the team supervision
- development of a team handover process and protocols for patients that actively involves the registrar, supervisor and supervisor team
- teaching plan is in place
- feedback from both registrar and supervisor each tern about the remote model.
How will it work?
Each remote location will have a remote supervisor who meets vocational training standards as a supervisor and the practice/clinic will be accredited according to the RACGP standards. The remote supervisor will have extensive experience as a supervisor and will be familiar with rural context or with AMS. There will be a designated onsite practice manager who will be responsible for the non-clinical component of the registrar’s supervision. This will often be the clinic manager or an experienced remote area nurse.
Within each location there will be a process for selection and matching of the GP Registrar to the remote supervision model. This is undertaken to ensure no obvious barriers or conflicts to progression of supervision.
Allowance for protected teaching time in the supervisor’s weekly schedule is set aside, with time quarantined to be conducted either face-to-face or via webinar/videoconference during normal hours unless alternative arrangements are in place.
The Registrar will be able to source assistance from experienced GP supervisors in all clinical situations. If any of the practice team or Registrar deem a situation an emergency and no onsite GP Supervisor; emergency protocol to be followed which will include utilising the QHealth or Retrieval Services 24 hour advice.
The remote supervisor to provide debrief and support as appropriate.
What are the risks?
The model at a given remote practice will actively develop an internal risk management/mitigation strategy and plan (inclusive of level of supervision required by the determined level of competence of the GP Registrar). The model will include a process for addressing certain situations; emergency or complex case, for monitoring and evaluating compliance and adherence with protocol and procedures and QRME and College standards. The risks identified with this model are:
- unplanned availability of a remote supervisor
- cultural competency and safety
- cost of the model
- compromised patient safety
- compromised GP registrar safety
How will the risks be managed?
In terms of unplanned availability of a remote supervisor, the risk will be managed by planned escalation approach for access to supervisor if allocated supervisor is not available. A multipronged approach using web-based, videoconference and mobile phones ensures access to supervision is guaranteed. Access to education and resources of QHealth/RFDS emergency services.
For address risks in cultural competency and safety, QRME will introduce a cultural support program as part of the placement plan. This includes local cultural network/contacts and the QRME cultural mentor. Regular contact and defined roles and responsibilities will be documented.
To mitigate risks for cost of the model – current supervision, practice and teaching payment can be supplemented by funding allocated via the Closing the Gap program for AMS. Any increased QHealth supervision costs budgeted and accounted for by local health districts.
To mitigate risks for compromised patient safety, the GP registrar will be required to complete an emergency medicine course before staring in post and will form a component of the selection criteria. Robust supervision plan and critical incident plan will also be in place. The remote supervision model will be under scrutiny throughout the trail and an ‘issue log’ maintained as part of the formal evaluation.
Working hours and the GP registrar’s wellbeing will also be checked on a weekly basis via the quarantined supervision and training time. Patient caseload and case mix will be monitored and analysed to ensure that the registrars are allocated patients and clinical presentations which fit their experience and expertise.